The Editorial Implications of Pressure Ulcer and Pressure Injury

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Lia van Rijswijk, DNP, RN, CWCN

It’s been almost 2 years since the National Pressure Ulcer Advisory Panel (NPUAP) changed the term pressure ulcer to pressure injury and made changes to previously used staging definitions.1 Why, then, do Ostomy Wound Management publications often contain both terms?

This not the first time terms or staging definitions have changed. In fact, someone asked me not too long ago if the terms decubitus ulcer, bed sore, pressure sore, pressure ulcer, and pressure injury all refer to the “same thing.” There also used to be a wide variety of staging systems. Following the adoption of a unified staging system at their 1989 consensus meeting, the NPUAP added/edited ulcer staging definitions in 1997 and in 2007.2-4 In contrast to previous changes, the 2016 revisions are more consequential because both the terminology and the definitions changed. For example, the 2007 pressure ulcer definition, “localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction,” differs from the 2016 pressure injury definition “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful and occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear also may be affected by microclimate, nutrition, perfusion, comorbidities, and the condition of the soft tissue.” In another example, a Stage 2 pressure ulcer was defined as, “Partial-thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister4”; whereas, the 2016 definition of a Stage 2 pressure injury is, “Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD) including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).”5 

While the actual and potential implications of these changes continue to unfold, OWM had to make an editorial decision. Do we ask authors to change all descriptions of pressure ulcers to pressure injuries? Do we, during the editorial process, change all references to the new terminology? Clearly, we did not choose those options. Rather, we opted to take the more complicated but, in our opinion, more scientifically accurate and consistent approach. If a study was conducted using the definition of pressure ulcers (and accompanying stage definitions), the term pressure ulcer is used. If a study was conducted using the 2016 definitions and staging descriptions of pressure injuries, the term pressure injury should be used. Similarly, when describing a study where clinicians used the pressure ulcer staging system, it should not be “renamed” a pressure injury study. 

As a result, authors will continue to be asked to use the term that was actually used in the study/studies. Thus, for now in OWM you will continue to see both terms. We hope you agree with our decision that accuracy is our first priority. 

References

1. National Pressure Ulcer Advisory Panel (NPUAP). National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. April 13, 2016. Available at: www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-c.... Accessed May 17, 2018.

2. National Pressure Ulcer Advisory Panel. Pressure ulcer prevalence, cost, and risk assessment: consensus development conference statement. Decubitus. 1989;2(2):24–28.

3. Henderson CT, Ayello EA, Sussman C, et al. Draft definition of stage I pressure ulcers: inclusion of persons with darkly pigmented skin. NPUAP Task Force on Stage I Definition and Darkly Pigmented Skin. Adv Wound Care J Prev Heal. 1997;10(5):16–19.

4. Black J, Baharestani, M, Cuddigan J, et al. National Pressure Ulcer Advisory Panel’s updated pressure ulcers staging system. Adv Skin and Wound Care. 2007;20(5):269–274.

5. National Pressure Ulcer Advisory Panel. NPUAP Pressure Injury Stages. Available at: www.npuap.org/resources/educational-and-clinical-resources/npuap-pressur.... Accessed May 17, 2018.

The opinions and statements expressed herein are specific to the respective authors and not necessarily those of OWM or HMP. This article was not subject to the Ostomy Wound Management peer-review process.